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injury to cranial nerves in relation to such fractures Fractures of the base are often dif cult to detect in plain skull lms, but their presence should always be suspected if any one of a number of characteristic clinical signs is in evidence Fracture of the petrous pyramid often deforms the external auditory canal or tears the tympanic membrane, with resultant leakage of CSF (otorrhea); or, blood may collect behind an intact tympanic membrane and discolor it If the fracture extends more posteriorly, damaging the sigmoid sinus, the tissue behind the ear and over the mastoid process becomes boggy and discolored (Battle sign) A Basal fracture of the anterior skull may also cause blood to leak into the periorbital tissues, imparting a B characteristic raccoon or panda bear appearance The presence of any of these signs calls for CT scanning of the skull base using bone window settings to detect a fracture The existence of a basal fracture is commonly indicated by signs of cranial nerve damage The olE factory, facial, and auditory nerves are the ones most liable to injury, but any one, including the twelfth, may be damaged Anosmia and an apparent loss of taste (actually a loss of perception of aromatic avors, since the elementary modalities of taste are unimpaired) are frequent sequelae of head injury, especially with falls on the back of the head In the majority of cases the anosmia is permanent If unilateral, it will C D not be noticed by the patient The mechanism of these disturbances is thought to be a displacement of the Figure 35-1 Mechanisms of craniocerebral injury A Cranium distorted by forceps (birth brain and tearing of the olfactory nerve laments in injury) B Gunshot wound of the brain C Falls (also traf c accidents) D Blows on the chin ( punch-drunk ) E Injury to skull and brain by falling objects [Reproduced by per- or near the cribriform plate, through which they mission from Courville (a study based on a survey of lesions found in a series of 15,000 course A fracture in or near the sella may tear the stalk autopsies)] of the pituitary gland, with resulting diabetes insipidus Rarely such a fracture may cause bleeding from a pre-existing pituitary adenoma and produce the syndrome of pirebral injury Even in fatal head injuries, autopsy reveals an intact tuitary apoplexy (page 577) A fracture of the sphenoid bone may skull in some 20 to 30 percent of cases (see also page 754) Conlacerate the optic nerve, with blindness from the beginning The trariwise, many patients suffer skull fractures without serious or pupil is unreactive to a direct light stimulus but still reacts to a prolonged disorder of cerebral function, largely because the energy light stimulus to the opposite eye (consensual re ex) The optic of a blow is dissipated in the fracture disc becomes pale, ie, atrophic, after an interval of several weeks The modern trend is to be concerned primarily with the presPartial injuries of the optic nerve result in scotomas and a troubleence or absence of brain injury rather than with the fracture of the some blurring of vision skull itself Nevertheless, fractures cannot be dismissed without Complete oculomotor nerve injury is characterized by ptosis, further comment for several reasons The presence of a fracture a divergence of the globes with the affected eye resting in an abalways warns of the possibility of underlying cerebral injury Overducted and slightly depressed position, loss of medial and most of all, brain injury is estimated to be 5 to 10 times more frequent with the vertical movements of the eye with diplopia, and a xed, dilated skull fractures than without them and perhaps 20 times more frepupil, as described in Chap 13 Diplopia that is worse on looking quent with severe and multiple fractures Moreover, fractures asdown, and compensatory tilting of the head suggest trochlear nerve sume importance by indicating the site and possible severity of injury In a series of 60 patients with head injury, Lepore found brain damage, in providing an explanation for certain cranial nerve that fourth nerve palsy was the commonest cause of diplopia, ocpalsies, and in creating potential pathways for the ingress of baccurring unilaterally twice as often as bilaterally, followed in freteria and air or the egress of cerebrospinal uid (CSF) In all these quency by damage to one or both third nerves, then, least often, a respects, fractures through the base of the skull are of special sigunilateral or bilateral sixth nerve palsy Five of his patients had ni cance, more so than those of the cranial vault, and are considpalsies that re ected damage to more than one nerve, and seven ered below had supranuclear disorders of convergence The long subarachnoid course of the fourth nerve is usually given as the explanation for Basal Skull Fractures and Cranial its frequent injury, but this mechanism has never been validated Nerve Injuries These optic and ocular motor nerve disorders must be distinguished from those due to displacement of the globe as a result of direct Some of the major sites and directions of basilar skull fractures are injury to the orbit and the oculomotor muscles indicated in Fig 35-2 One can readily perceive the possibilities of.

middle ear and disruption of the ossicular chain (conduction deafness) Also, vertigo must be distinguished from the very common symptom of posttraumatic giddiness discussed in a later section A fracture through the hypoglossal canal causes weakness of one side of the tongue It should be kept in mind that blows to the upper neck may also cause lower cranial nerve palsies, either by direct injury to their peripheral extensions or as a result of carotid artery dissection, either of its cervical or intracranial segment

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A basal fracture through the sphenoid bone may lacerate the internal carotid artery or one of its intracavernous branches where it lies in the cavernous sinus Within hours or a day or two, a dis guring pulsating exophthalmos develops as arterial blood enters the sinus and distends the superior and inferior ophthalmic veins that empty into the sinus The orbit feels tight and painful, and the eye may become partially or completely immobile because of pressure on the ocular nerves traversing the sinus (Fig 14-4) The sixth nerve is affected most often and the third and fourth nerves less frequently Also, there may be a loss of vision due to ischemia of the optic nerve and retina; congestion of the retinal veins and glaucoma are additional factors in the visual failure Some 5 to 10 percent of stulas resolve spontaneously, but the remainder must be obliterated by interventional radiologic means (by a detachable balloon inserted into the carotid artery via a transfemoral catheter) or by a direct surgical repair of the stula (see Stern) Not all carotid-cavernous stulas are traumatic They may occasionally occur with rupture of an intracavernous saccular aneurysm or in Ehlers-Danlos disease, where the connective tissue is defective; or the cause may be unexplained

17 D The primary function of a PIF is to configure the memory usage of applications that run in a DOS shell By modifying a DOS application s PIF, you can also modify its window size, text font, and text resolution A, to configure the appearance of applications that run in DOS mode, is incorrect A PIF is used specifically for configuring the appearance and behavior of DOS applications that are run within Windows, not in DOS (real) mode B, to configure shared files for 32-bit Windows applications, is incorrect PIFs are associated with non-Windows applications that use the DOS shell only C, to store information about the creation and modification dates of a nonsystem file, is incorrect PIFs are used only with non-Windows executable files 18 D The default printer will be used by Windows applications unless a different printer is specified within the application By setting a printer as the default, you are instructing Windows applications to use that printer unless you specify otherwise A, the printer that you plan to use as the default must be installed first, is incorrect You can set any printer as the default by right-clicking it and selecting Set as Default B, by default, the Printers window in the Control Panel displays only the default printer, is incorrect The Printers window displays all printers in the system C, applications can print only to whichever printer is set as the default, is incorrect Applications can print to any printer in the system, as long as the printer is selected within the application 19 A When you enable printer spooling in Windows, print jobs will be passed on to the Windows spooler by the originating application From there, they will be saved to the hard drive The application can then resume other functions Windows will retrieve the print job from the hard drive, process the job, and send it to the printer B, the application, rather than Windows, will send the print job to the printer, is incorrect In fact, this is the opposite of print spooling When you elect to have applications send print jobs directly to the printer, you disable printer spooling C, Windows will poll all printers and send the print job to the first available printer, is incorrect Windows will send print jobs to the printer specified within the originating application There is no option to configure Windows to send print jobs to the first available printer D, print jobs will be processed in the order of the originating application s priority, is incorrect Print jobs are processed in the order in which they are received by Windows Applications cannot be given printing priorities 20 C Set the data format the EMF EMF is the default rendering language of Windows If the data format is set to RAW, Windows must first translate the print job into the printer s native code This can take longer than sending EMF print jobs, so the print process might appear slow A, disable printer spooling, is incorrect If you disable spooling, the application itself, rather than Windows, will control the print job The print job won t arrive at the printer any.

Pneumocephalus, Aerocele, and Rhinorrhea (Cerebrospinal Fluid Leak)

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Figure 35-2 The course of fracture lines through the base of the skull Arrows indicate point of application and direction of force (Reproduced by permission from Courville)

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